Mr Page · Prevention of Future Deaths report

On 6th May 2014 I commenced an investigation into the death of Ian Page then aged 86. The investigation concluded at the end of the inquest on 12th September 2014. The conclusion of the inquest was one of accidental death. The medical cause of death was:
1(a) fracture of cervical spine
1(b) ischaemic heart disease, fracture of left hip

(1) Mr Page was admitted to Withybush General Hospital on 26th April 2014 following a fall at home.
(2) He underwent surgery at the Hospital. Following the operation Mr Page remained in hospital. Mr Page had dementia and would make repeated attempts to leave his bed despite his recent surgery.
(3) On the 28th April at approximately 23.10 hours he got up from his bed and fell fracturing his cervical spine.
(4) His condition deteriorated and he died on the 2nd May 2014.

1. There was a training need identified regarding communication following patient handover.
2. No risk assessment was carried out on Mr Page identifying the risk of falls.
3. There was no low bed available to Mr Page.
4. A review of the provision of nursing staff was identified when patient circumstances require greater staffing levels.